Colonial Care Center
Facility I.D. Number: 6010441
Date of Survey: 07/15/2003
All necessary precautions shall be taken to assure that the residents environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
Hot water available to residents at a shower, bathing and hand washing facilities shall not exceed 110 degrees Fahrenheit. (A, B)
Protective measures, such as but not limited to, installation of a mixing valve, limited access to controls, and checking water temperature daily at various points, shall be implemented to insure that the temperature of hot water available to residents at shower, bathing and hand washing facilities shall not exceed 110 degrees Fahrenheit. (A, B)
Based on observations, record review and interviews, the facility failed to provide safe hot water to residents. Hot water on the south half of the building was found to be between 135 degrees F and 140 degrees F at bathing and hand washing locations accessible to residents at 10:30 A.M. on 07/08/03.
The facility staff identified three confused residents (R32, R33, and R34) who would have access to these extreme hot water temperatures, placing them at risk for burns.
1. On 07/08/03 at 10:30 A.M., the hot water was checked on the south end of the building and was found to be extremely hot. The following temperatures were then recorded:
135 degrees F at the lavatory off room 219
140 degrees F at the tub in the tub shower room on the south east hall
132 degrees F at the lavatory off room 218
140 degrees F at the lavatory off room 210
135 degrees F at the lavatory off room 203
140 degrees F at the lavatory off room 202
Thermometer #A11 was used to measure temperatures.
The E4, Maintenance Supervisor, had been notified by staff about the extremely hot water. At 10:45 A.M. when the only other shower/tub room was checked the hot water valve produced cold water. E4 was in the janitors closet which contains the hot water tank draining the recirculating line. E1, Administrator, and E2, Director of Nursing, were then informed of the hot water temperatures and concern about giving showers. E1 and E2 suspended showers at this time.
At 11:55 A.M., the hot water was recorded at 128 degrees F at the bath tub in the south central shower/tub room. The facility's thermometer on the hot water heater, past the mixing valve, was registering 130 degrees F. It was brought to the attention of E1 again. E1 said she had contacted E5, Regional Maintenance Supervisor, to come and check on the hot water problem.
The hot water distribution system that had elevated hot water temperatures serves one half of the resident use areas or the south end of the building. E1 and E2 identified three confused residents (R32, R33, and R34) who are capable of turning on the hot water.
In an interview on 07/08/03 with E2, it was stated that five residents (R29, R30, R19, R31, and R24) had received showers on the south hall the morning of 07/08/03 with assistance of E6. All five residents were evaluated for burns and none were found. E6, CNA, stated in an interview, at 1:10 p.m. on 07/08/03, she noticed that the water was hotter than normal but that she adjusted the water with cold water to a safe level. E6 said she told E2 about the hot water. E6 said she had not noticed the hot water being elevated before this morning.
E2 was asked, after the interview with E6, if she was notified by E6 of the elevated hot water. E2 said that after the hot water problem had been identified, E2 asked E6 if she had noticed the hot water being warmer then normal and at that time had told her. No other staffs that were interviewed were aware of any hot water problems.
E4, Maintenance Director, was asked about how the hot water temperatures are monitored. He said he checks them daily and records them. E4 produced a log of water temperatures indicating that at 7:00 A.M., on 07/08/03, the hot water temperatures on the south end were between 109 degrees F and 110 degrees F, and on the north end were at 110 degrees F. The surveyor measured hot water temperatures between 132 degrees Fs and 140 degrees F at 10:30 A.M. on the south end and between 85 degrees F and 89 degrees F on the north end at 11:00 A.M. on 07/08/03.
The hot water temperatures were checked by the surveyor the rest of the survey and were found not to exceed 110 degrees F.